Which of the following does NOT apply to medical record documentation?
Responda
complete
timely
accurate
length
Questão 2
Questão
What will the electronic health record reduce?
Responda
cost
medical errors
coding jobs
confidentiality issues
Questão 3
Questão
Which of the following is NOT considered a common documentation error or deficiency?
Responda
late entry
date inconsistency
location discrepancy
missing/incorrect patient information
Questão 4
Questão
Which of the following is included in patient demographics?
Responda
name, address, and telephone number
date of birth and gender
insurance and billing information
all of the above
Questão 5
Questão
Which of the following would NOT be considered a documentation error?
Responda
missing patient's date of birth
inconsistencies in date
missing operative report
missing physician's signature
Questão 6
Questão
Implementation of the electronic health record offers many challenges. Which would NOT be considered a critical challenge?
Responda
control of cost
maintaining confidentiality
ease of storage
maintaining security of the healthcare record
Questão 7
Questão
Response to treatment, change in patient's diagnosis, and progress towards discharge are all pieces of information found in this medical report.
Responda
Progress Note
History and Physical Examination
Procedure Note
Discharge Summary
Questão 8
Questão
"The patient had mumps and measles as a child. She has suffered from community-acquired pneumonia twice in the past 15 years. Her last hospitalization occurred earlier this year after being involved in a car accident. The patient's clavicle was repaired at that time." This information is found on the ___ section of History & Physical exam.
Responda
Review of Systems
Social History
Physical Examination
Past Medical History
Questão 9
Questão
Determine which of the following report types would ONLY be found in an inpatient medical record.
Responda
Consultation
Discharge Summary
Operative Report
Progress Note
Questão 10
Questão
Which of the following is something that makes implementing EHR difficult?
Responda
they are costly to maintain
employees must be trained on a new system
EHR systems can be hacked and medical information exposed
all of the above
Questão 11
Questão
The ___ is the name of the U.S. government agency tasked with guiding the nationwide implementation of health information technology.
Responda
Regional Health Information Organization
Office of the National Coordinator
Health Level Seven
none of the above
Questão 12
Questão
One of the benefits to using an encoder is ___
Responda
speed and efficiency
security
more bandwidth
all of the above
Questão 13
Questão
Medical professionals can use the ___ to identify, match, merge and cleanse patient records to create an index to obtain a complete view of a patient.
Responda
nationally organized patient index
system-wide patient control index
enterprise-wide master patient index
none of the above
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